People with coverage through work pony up for monthly premiums, after all. And those with taxpayer-funded health insurance should face financial consequences if they miss doctor’s appointments or make expensive trips to the emergency room for minor ailments, the administration’s thinking goes.

But critics of the new proposal, which will require approval from the federal government, argue that even a small monthly premium is unaffordable for many who rely on the program for low-income Mainers. Patients can have legitimate reasons for failing to make medical appointments and resorting to the ER too often, they say.

These provisions, as part of the LePage administration’s broader proposal, drew several dozen people to a public hearing Wednesday at the Cross Insurance Center in Portland.

Charging monthly premiums

Under LePage’s plan, “able-bodied” adults on MaineCare would be charged between $14 and $66 per month in premiums, depending on their income. Those who don’t pay the premium would lose their coverage after a 60-day grace period. This is among the provisions that would “support a level of personal responsibility” among MaineCare beneficiaries, the administration wrote in its proposal.

In other states that charge such premiums, collecting the monthly payments from beneficiaries is costing more than the program brings in, Mitchell Stein, an independent health policy consultant, said at Wednesday’s hearing. For example, Arkansas spent $12 million last year to implement its premium program after collecting only $384,000 from members the previous year, he said.

Critics also argue that many people who are eligible for MaineCare can’t afford to pay monthly premiums, so they’ll get dropped from the program or won’t bother to apply in the first place. Without insurance, they’ll likely fail to get needed medical care, grow sicker and end up costing the health system more, according to research by the Kaiser Family Foundation.

Penalties for unnecessary ER visits

The LePage administration also proposes to charge MaineCare recipients if they visit the emergency department unnecessarily. Emergency department visits are among the most expensive settings for treatment, and patients who frequent them are considered a major factor in rising health care costs in Maine and across the country.

DHHS already reduced payments to hospitals for non-emergency visits to emergency departments and has targeted the MaineCare members who use them the most for case management. Now MaineCare members need an incentive to seek out primary care or treatment in other settings, such as urgent care clinics, the administration argues.

DHHS wants to charge nearly all MaineCare beneficiaries who visit an emergency department but aren’t subsequently admitted to the hospital a $20 co-payment. Their bill also would break down the expenses associated with their emergency department visit to “provide information to members regarding the cost of their care to the taxpayers of Maine,” DHHS wrote in its proposal.

At Wednesday’s hearing, Peggy Marchand spoke against the emergency department penalty, describing how after the sudden death of her infant daughter decades ago, she took no chances in rushing herself and her other children to the hospital following various injuries.

“After 40 years of marriage and several rushed trips to the ER, our dying baby was the only family member ever to have been admitted to the hospital after an ER visit. … Who gets to decide what is and what is not an emergency?” Marchand, part of the Maine Health Care Is A Human Right Coalition, said.

Fees for missed appointments

Missed appointments are a significant problem for doctors, therapists and other providers who treat MaineCare patients, according to the Maine Department of Health and Human Services, which administers the program.

“Not only is the provider denied payment. … But other MaineCare members, who could potentially have been seen in that time slot, miss an opportunity for care,” the department wrote in its reform proposal.

Some providers refuse to treat MaineCare patients for that reason, among others.

Under the plan, providers could charge MaineCare members for missed appointments, up to the amount that MaineCare would have reimbursed the provider for the service. That could easily run into the hundreds of dollars for many common health care services.

Opponents of the plan contend there are legitimate reasons for missing appointments. Many MaineCare members rely on state-provided transportation that several speakers at Wednesday’s hearing described as unreliable, while others may be too sick to travel or struggle to find child care.

Those three provisions are the “cost-sharing initiatives” within LePage’s proposal to further overhaul MaineCare. His administration also seeks to make MaineCare enrollees subject to work or service requirements and to impose a $5,000 asset limit.

If the federal government approves the proposal — DHHS is hoping for a green light in January 2018 — nearly all of the provisions would take effect within six months. The premium requirements would kick in on July 1, 2018.

The administration scheduled a second public hearing on the proposal for Thursday morning in Augusta.